Lilavati Hospital, Mumbai
</b> It is really a great pleasure for me as a president of CSI to interview a very important person as a president of API. I think Shashank Joshi needs no introduction to this audience. He has been the editor of JAPI and he has been the president of API and I think he is a president of many organizations, which I even do not recollect, very powerful and frolic speaker and a perfect academician with lot of knowledge about the research especially in cardio diabetes. Ladies and Gentleman, I present to you Shashank Joshi and I have some very important issues to discuss with you, Shashank. The first important issue is about the role of edible oil and then I will ask you something about the cardio diabetes, how do you manage these people and then what is the role of central aortic pressure or the ambulatory blood pressure monitoring and you give all the insights possible, which we can manage our patients very well? There has been lot of issues on the edible oil, which I am sure I discussed with you many times in the WHO meeting also as well as in the ICMR meeting. We would like to have the words of wisdom from you. Your recommendation is a policy of the government of India and globally about the role of oil, the quality of oil and the composition of oil, which is the best oil in today’s scenario, which as a message you give it to everyone should be utilized if you want to protect heart problems or the stroke problems in a country like India or to control cardio diabetes, Shashank?
</b> So, thank you Prof. Chopra.I think, I should congratulate you because you have been on the epitome of education, prevention, treatment and rehabilitation and I think the credit goes to you for popularizing this. You ask me the most important question, I think one of the single most important question I am asking in any medical meeting or even lay people meeting where I go, is which cooking oil to use? How much to use? And what do we do with it? So the answers were very elusive couple of years back, because we were totally wedded to the west and the western influence of olive oil, canola oil and mustard oil was all there. But the Indian government particularly, their lab, National Institute of Nutrition and ICMR came out with guidelines based on WHO and FAO recommendations for vegetable oils. We know that not a single vegetable oil meets all the requirements of the fatty acid composition. We need a little bit of saturated fat, we need a little bit of MUFA and we need a little bit of PUFA. What I mean by MUFA is monounsaturated fatty acids. What I mean by PUFA is polyunsaturated fatty acids. So, we need to balance all the three and when you need to balance all the three, we also need the right ratio of omega 3 to omega 6 fatty acid ratio between 1
</b> Shashank, I think it is very important your statement was may be blend, why may be blend? It should be blend!
</b> I think blend is a current solution. Current solution offered to us from NIN is the blend and therefore blending is the answer okay to the current situation, which is available and we are researching on more and more blend. So, I am sure Indian government does not allow a blend beyond two vegetable oils.
</b> Rice blend oil or safflower oil, the blending is also 70
</b> You can do both. Both the blends are available. 80
</b> So, I think the message is very clear by Dr. Shashank Joshi.If you really want to use a so-called “ideal” edible oil in a food to prevent the cardiometabolic issues or diabetes control or reduce the morbidity and mortality, I think the best oil is the blended oil and the blend should be 70
</b> So, you asked me a plethora of questions and I think it is very difficult to answer, but I will try to do justice to all of them. I think the first thing which you say is we are the metabolic syndrome capital of the world, we have cardiometabolic disease.We are of course the second largest country in the world, but it is just not because China is one and India is two and the geography of India and China is large, and the population is large, which is why we are having these high incidents of heart disease. It is basically because we have changed our socioeconomic graph very quickly. We have become affluent, we have become urbanized, we are living in concrete jungles and our physical activity has gone down tremendously. So, we are eating the wrong foods. We are not eating foods on time. We are all wedded to fast food cultures, which is very, very detrimental to our health. We are wedded to colas, which are nothing but sugar bombs because if you have any cola for any matter of fact it is 13 teaspoon full of sugar and therefore it is something which we need to ban it. It is worse than cigarette smoking I feel sometimes. Then, we eat a lot of foods, which have trans fats, which is not good at all. It is going to lead to a lot of hypertension and diabetes. We are a salt capital of the world. We consume too much of salty foods.It is not just sugars.Sugar is one of bomb and you know that WHO has recently declared that sugar could be equivalent to tobacco.But we also eat too much of salt and that leads to lot of hypertension and that is something which we know our papads, the pickles, and the chutneys which we eat they have a lot of indirect invisible salt and that sodium needs to be curtailed so that is an epidemic of hypertension and diabetes exploding in India very rapidly, very quickly, very fast and then we have westernization through multinationals which are trying to influence our culture. For example, they are trying to insert cornflakes in our breakfast. Cornflakes are poison flakes. You cannot have them. You need to have traditional Indian breakfast.The best food is what our grandmothers cooked, but probably we have to compound it with physical activity and then probably use functional foods.So, probably if you really want to stem cardio diabetes epidemic, we really need to make an effort on diet, exercise, and living happily, because we are continuously living in a stressed out environment, not sleeping on time and not eating well.Therefore, I think we really need to stem this epidemic of diabetes. Diabetes is nothing but too much of carbohydrates, too much of fat and too little proteins. So, Indians are thin fat Indians and because we are thin and fat that means what happens with us is we put a lot of fat in our abdomen on our body or body composition and that is why we have generation of blood pressure as well as this thing. In fact, we have done studies to show you just cut the carbohydrates, the simple sugars, and you know even our blood pressure will come down, just by restricting sugar and salt. I think these are simple things which we need to do. Then, you highlight two important tenets in blood pressure monitoring; one is central aortic pressure and secondary is the role of ambulatory blood pressure monitoring. We all know the white coat effect. We all know that we need to do away with the mercury manometer, but I still feel we measure it because some of these machines, the electronic gadgets may not be absolutely sacrosanct to measure it. A 24-hour blood pressure monitoring is here to stay and it is ambulatory blood pressure monitoring. It is like a graph which you get which actually tells you two things which are critically important; one is the nocturnal blood pressure because the nocturnal surge of the blood pressure which occurs early morning is actually the killer pressure and if you need to pick that up and you need to ensure that the nighttime blood pressure and the nocturnal dipping has to be picked up, you need to do a 24-hour blood pressure monitoring. Secondly, when you are free-living outside and you do a 24-hour blood pressure monitoring, you clearly get an idea independent of the doctor’s office which eliminates the white coat effect to some extent, I would not say totally but we will try to get you a delineate blood pressure control better, because there is a lot of blood pressure variability. Interindividual and intraindividual that means within the same individual on three different days, may be a weekday or day when he has a meeting and when he has no meeting, if you do blood pressure measurement you will get a blood pressure variability. We can even measure glucose variability like that, but blood pressure variability is important.Also, just doing a 120/80 goal of blood pressure is not enough. You need to measure central aortic pressure because if you measure that and you highlight that you can get into that better. So, it is important to recognize that. Because I am a metabolic physician beyond central aortic pressure and 24-hour blood pressure monitoring, we need to look at the kidneys.Kidneys are the prime targets of uncontrolled hypertension and therefore the glomerular hypertension leaks out as microalbumin and that does not get controlled and that is where medications like ACE or ARBs, mainly ACE, I think ARBs have been wrongly propounded. I feel ACE still remains the cornerstone just because of the over-highlighting of cough, people have really not done and looked at the robust outcome data which HOPE trial had that you need to ensure that you need to take care of that blood pressure in the kidney which comes out as microalbumin much before actual hypertension comes out and therefore it is important to recognize that we have agents like tissue-specification ACE inhibitors like say ramipril or perindopril, which can make a difference to the microalbumin save you the kidneys because we are having a big renal failure problem which is coming up and when your blood pressure and diabetes combine together as a twin epidemic which jeopardize or actually propounded not in arithmetic proportion but in geometric proportion but I still feel Dr. Chopra the answer is in prevention. I congratulate you for having this outstanding world conference on preventive cardiology because you have been consistently highlighting on preventive cardiology.The era of clinical cardiology and preventive cardiology has taken a back seat because we are in an era of interventional cardiology,but we need to remember that we need to intervene through prevention. Prevention is the best intervention because I think that is what superior doctors are supposed to do.
</b> I think Dr. Shashank has given a very, very clearcut and a very vivid viewpoint that it is the preventive cardiology which is your real intervention and not the intervention as a preventive cardiology. Dr. Shashank was very categoric and very specific that there is so much of variability in the second-to-second, minute-to-minute and event-to-event in the blood pressure at times it is not possible to know where what is happening and every individual is different. He used one very specific word morning surge of blood pressure which is not seen in every individual. If is different in different people and the role of central aortic blood pressure is very, very important which is a real hallmark to decide the therapy in most of the patients and second thing about the ambulatory blood pressure monitoring.I think the data has been where he says blood pressure load if a person has got more systolic load or a diastolic load at a certain point of time which we can see by ambulatory blood pressure monitoring, we can control it very well and the role of ACE inhibitors before the microalbuminuria sets in. He said it is a preventative strategy. People use a very less dose of ACE inhibitors like ramipril. The patient use a higher dose or it is optimum dose and should not be scared of side effect like cough, but we should really prevent the damage to the kidneys.So, I think it is very, very important message given by a Dr. Shashank Johsi on the morbidity and mortality produced by uncontrolled hypertension and uncontrol diabetes in individuals.So, meticulous control is the answer and it is possible if we follow the patients very carefully clinically given all the preventative strategies and use the medicines in a very meticulous manner and follow them up so that there is no entry of the morbidity on a long-term basis and the role of central aortic pressure is very well highlighted and the ambulatory blood pressure monitoring.I want to ask one thing Shashank, We see a lot of elderly patients after the age of 55 or 60 and we will see a lot of postural hypotension in these patients which is either iatrogenic, by some drugs or it is because of autonomic insufficiency produced by diabetes itself, so we are ill-choosing some drugs intervention and we see also some patients who are on beta-blockers for a long time as they grow old because of autonomic insufficiency, there is a little variable requirement of beta-blockers. We would like you to highlight on the role of drug intervention in elderly and the role of ambulatory blood pressure monitoring in elderly and the central aortic pressure in the elderly.
</b> So, elderly postural hypotension what you are talking about is a very important entity and many a times that the culprit are the drugs, but I think because we have a larger menu available with us, this is the time when we can use it better.Secondly, systolic blood pressure is chaste above 60 more aggressively, but the guidelines have actually come down on the aggressiveness of tight blood pressure control and therefore we need to recognize that particularly in the elderly population, particularly when you are having the situation of an autonomic dysfunction or a situation where you are leading to a lot of postural hypotension, so these are the situations where the degree of blood pressure control needs to be optimized. A 24-hour blood pressure monitoring or central aortic blood pressure does come as a tool and a rescue tool to us, but I think we need to balance out. Sometimes, we have to investigate some of these patients who have consistent orthostatic hypotension and sometimes add a fludrocortisone sometimes to there in some of these patients particularly because we could see that there could be a salt deficiency and a cortisole deficiency. So, you need to recognize sometimes and delineate some of these patients who get recurrent orthostatic hypotension.Also, autonomic dysfunction, once it sets in, it is actually a very poor prognosticator and a lot of our patients do have autonomic insufficiency and you need to investigate it systematically and treat it systematically and we do have drugs likely fludrocortisone from the endocrinology endpoint, which we can use appropriately so that we can handle these difficult problems particularly in elderly of postural hypotension better. Currently, we are living in a good era.I say we are living in a good era because we are in era where therapeutics is at it is speak, but we still need more and more tools to pickup responders and non-responders and to pickup people who will develop side effects and probably a day will come through snips or genome chips, where it is possible for us to identify that a patient will develop postural hypotension, second patient will not develop postural hypotension and I am certain that just by giving point 0.1 mL of blood we will be able to find out who will get postural hypotension and who will not get postural hypotension and I think that will be most useful. The pharmacogenomics tools will be most useful probably in the elderly population.
</b> Dr. Shashank Joshi, I think you gave a very good remark that ACE inhibitor is the mainstay for the treatment so far as prevention of microalbuminuria is concerned. But there was recently a lot of discussion on ACE inhibitor no doubt about it, in ARB also there is a lot of debate to use telmisartan or irbesartan what is your viewpoint on the telmisartan versus olmesartan or telmisartan is the answer or olmesartan is the answer. What do you say on this?
</b> So, I think let me make this very clear. If you look from pure cardiovascular outcome trials,the data was consistent from the largest trial, which was HOPE trial on ramipril and subsequently on tissue-specific ACE inhibitor.So, consistent CV outcome data was with ACE inhibitors. Whenever ACE inhibitor was intolerant, then one moves to ARB. Unfortunately, in India, we see that the tomtoming of ARBs was more powerful and just fundamentally because of that you see that the sartans have gained credence. Sartans had a challenge. If you look some of the data in sartans, they actually increased incidence of myocardial infarction and that has been put under a lot of scrutiny.So, sartans are definitely not my first choice agents, particularly when I am looking from the cardiovascular myocardial infarction standpoint. It will always be an ACE inhibitor and if there is intolerance, then probably I would move to a sartan. Among these sartans, the metabolic sartan is telmisartan and therefore that has gained a wide popularity overall because of its metabolic impact on overall blood pressure control and the freedom from the cough or the bradykinin side effects which are predominately the kinin-bradykinin pathway, which predominately lead to lot of cough and that cough is made worse because we are living in a polluted environment and that is why probably it gets highlighted in a much bigger way and therefore then I would probably take pick on telmisartan, that does not mean other sartans not good enough. Sartans have now consistently shown more and more data, but I think if you look at the cardiology wisdom and if you look at even from the metabolic standpoint wisdom, the data is most robust scientist with ACE and if there is a challenge of intolerance, then the sartans come in play and among the sartans, probably the popular sartan has been telmisartan mainly because of its metabolic impact and the outcome they have generated.
</b> I see the message is very clear that the drug of choice is ACE inhibitors on first priority and in case there is intolerance or some not acceptability of this drug, we can go for sartan and out of the sartan the best is telmisartan because there is a huge data. There is a huge evidence-based data in sartan with telmisartan as compared to olmesartan and other sartans and I think this message should be taken practically and use ACE inhibitors as a first drug of choice if you really want to do a cardioprotection and reduce the prevalence of microalbuminuria and ambulatory blood pressure monitoring should be used more often. Central aortic pressure monitoring should be done more often so that we can really reduce the morbidity and mortality produced by uncontrolled hypertension or uncontrolled diabetes. I am very grateful to you Shashank for being with us and giving your message on the role of oil, role of drugs, and the role of normal pharmacological methods also and the aim is ultimate to reduce the morbidity and mortality, which is cardio-diabetes inflected.